Today, the Sunday Observer focuses on a highly contagious disease that can drastically impact on the health of a baby to be born. If a pregnant woman is infected by Rubella or German measles as it is sometimes called, during the first 3-4 months of her pregnancy, doctors say that severe and even fatal devastating effects can occur in the baby. There is a 90% chance of passing the virus on to her fetus which can result in miscarriages, still-births and heart and ear problems, low birth weight and low IQ - a range of birth defects collectively called Congenital Rubella Syndrome (CRS).
The Sunday Observer spoke to Consultant Epidemiologist, Ministry of Health Dr Deepa Gamage to find out how this deadly condition is caused and how it could be prevented.
Excerpts…
SO. Rubella is a disease that can affect anyone but dangerous if pregnant mothers are infected. Some mothers however still don’t know much about this disease that leaves lasting scars. Tell us, what is Rubella?
DG. Rubella is a viral disease caused by the Rubella virus (Rubivirus) which is highly contagious and can easily transmit from person to person. Rubella is also called German measles probably due to the similarity of the clinical picture of fever and the rash. Rubella is usually a mild illness but its impact on a newborn is devastating if it occurs during pregnancy.
SO. What are the likely complications of Rubella?
DG. If susceptible or not-immunised a pregnant woman would be exposed to an infected person and could get affected with Rubella. In such an instance, she can deliver a Congenital Rubella Syndrome (CRS) affected baby suffering from congenital abnormalities. The CRS includes eye defects such as cataracts, glaucoma, “microphthalmia”, heart problems, ear problems and many other neurological problems including mental retardation and developmental problems of the baby. This happens due to the teratogenic potential of the Rubella virus or the devastating effects of rubella infection on the fetus during pregnancy causing congenital infections leading to congenital abnormalities in the intrauterine baby.
SO. How is it transmitted?
DG. Rubella virus transmits through respiratory tract secretions during sneezing and coughing. Once the virus enters the body, it fights with the immune system and infection occurs after an incubation period of 14-21 days. This means, initial signs and symptoms occur after acquiring the virus into the body and the elapse of the incubation period. These individuals start spreading the disease even 7 days before the appearance of clinical signs and 2 to 3 days after the appearance of the signs.
SO. Is it contagious? Can you get infected by touching an infected person, shaking hands, hugging or kissing?
DG. Yes, it is contagious. Live viruses which remain in respiratory secretions are usually expelled to the air during coughing and sneezing. It can cause diseases to others if these viruses enter the other person’s respiratory tracts usually through the breathing of infected air born secretory particles with viruses. Any close contact at the time of the infectious period can spread the disease if it is related to favouring virus transmissions to the respiratory tract. Otherwise, handshaking alone will not transmit the virus.
SO. Symptoms?
DG. Initial symptoms of Rubella or the prodromal illness consist of mild fever ( around 39.0ºC), unfitness (malaise) , reddish eyes (conjunctivitis) and lymph node enlargements (behind the ear, and neck). The maculopapular, reddish rash occurs in 50–80% of Rubella-infected persons. The rash, usually lasting 1–3 days, starts on the face and neck and then gradually progresses down the body. However, nearly 20–50% of all Rubella infections occur without a rash and clinical disease may not be obvious. Joint symptoms (arthritis, arthralgia) can also occur during the acute disease.
SO. Signs of the symptoms in an infant or toddler?
DG. Fever and rash are the initial signs. If anyone gets fever and rash they need to visit a medical officer and test for Rubella. If it is confirmed, measures need to be taken to prevent its transmission to the community. If the infant or toddler gets fever and rash, it could be informed to the public health midwife or the public health inspector in the area.
SO. What is the treatment for someone with Rubella?
DG. Usually, it is symptomatic treatment after getting the disease. But, it’s important to take the vaccination to prevent Rubella. The currently available vaccine for Rubella prevention is “MMR” vaccination which includes a combination of measles and mumps. The affected individual may not need hospitalization based on the treatment, as it sometimes causes a milder illness. But, considering the Congenital Rubella Infection risk, it is important to inform the Medical Officer of Health (MOH) of the area or any Medical Officer in the closest health care institution to notify and investigate (test at the laboratory) for all fever and rash cases suspected of Rubella to exclude them as non-Rubella.
SO. Is there a cure for CRS?
DG. There is no cure for CRS. If a woman gives birth to a baby, with such congenital abnormalities due to CRS, then the child will not be normal. She has to take the child for different treatments and surgeries at different ages of the child to different specialists, which will cause a family problem, and a social and economic burden to the family and country.
SO. So what is the best way to prevent Rubella?
DG. The most effective preventive strategy is the vaccination against Rubella. This helps prevent both Rubella and CRS in the long run. Every woman should be made aware of this dangerous problem before becoming pregnant and encouraged to get immunized against Rubella virus or ensure that she is already immunized with previous rubella vaccination. Rubella vaccination with different schedule changes in the National immunization program has been practised since 1996. Rubella vaccination has achieved very high coverage and given promising results to the country in heading for its elimination.
The country has planned Rubella and CRS elimination by 2020. Sri Lanka is a country with mature Rubella immunization in the National Immunization Program and surveillance for Rubella and CRS, implemented by the Epidemiology Unit of the Ministry of Health. The country has the capacity to target elimination compared to other countries in the South East Asia Region.
SO. What is the role of vaccination to prevent Rubella?
DG. A single dose of Rubella vaccine is usually considered as providing lifelong protection. But two doses will give a better assurance of protection, enhancing lifelong immunity aiming at reducing the disease in the country, and thereby eliminate Rubella and CRS.
SO. What is the recommended vaccine?
DG. Rubella vaccine, MR vaccine or MMR vaccine can be given to prevent Rubella. All 3 vaccines were included in the National Immunization Program at different times and currently MMR vaccination is included in the National Immunization Program for the prevention of rubella.
SO. Is the MMR recommended for pregnant women? If not why?
DG. Actually, MMR should be given before pregnancy. Once a woman in the reproductive age is getting ready for marriage, she has to be protected with the Rubella containing vaccine before, even at childhood. Since the vaccine provides lifelong immunity, if the woman has received Rubella vaccination during childhood, that is usually adequate protection for Rubella and CRS. Rubella containing vaccines are not recommended during pregnancy. It needs to be taken before pregnancy and a woman can become pregnant 3 months after the vaccination. However, based on the country vaccination policies implemented over the years, almost all pregnant mothers who are currently delivering babies, are protected for Rubella and need to continue childhood vaccination to maintain this high population immunity levels.
SO. Tell us about your current Expanded Immunization Program.
DG. The national immunization schedule includes 2 MMR doses to be given to each child, provided through the MOH office delivery system of the vaccination. Field level immunization clinics conducted by the MOH team including Medical Officers of Health, Public Health Nursing Sisters and Public Health Midwives, ensure the provision of MMR 2 doses to all children at the age of 9 months for the first dose and 3 years for the 2nd dose. The Central Epidemiology Unit, Ministry of Health is involved in policy, program implementation, assuring vaccine quality, monitoring and evaluation of the program for the equal provision of vaccination to all in eliminating rubella and CRS in the country.
SO. Your message to parents ?
DG. 1. Vaccinate children at 9 months and at 3 years to protect them from Rubella and prevent CRS.
2. Inform of suspected Rubella cases, fever and rash cases-suspected of Rubella and CRS cases to the Public Health Inspector, Public Health Midwife or the MOH in the area or the Regional Epidemiologist in the District without delay for further prevention of the spread in achieving disease elimination in the country.